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FILE NAME: Z< DATE: K DOC#: Z< DOCUMENT DESCRIPTION :ZDZZs D/ZZ Occupational Medicine Advance Access published October 27,2007 Occupatwnal Media"" doi:IO.1093/occmedlkqmI14 Mesothelioma in vehicle mechanics: is the risk different for Australians? Michael A. Kelsh1,2, Valerie A. Craven3, Mary Jane Teta\ Fionna S. Mowat1 and Michael Goodrnan5 Background The question of whether vehicle mechanics have an increased risk of mesothelioma has important public health implications. Calculations of relative risk using case reports from the Australian Mesothelioma Registry CAMR) indicate increased risks; however, this contrasts with the results of 19 epidemiologic studies that have found no association. Aim. To evaluate potential explanations for the discrepancy of findings from epidemiologic studies and AMR reports. Methods We evaluated three hypotheses as possible explanations for the inconsistency between the AlvlRbased calculations and the findings from published epidemiologic studies: Ci) differences in exposure characteristics of Australian vehicle mechanics versus vehicle mechanics in North America and Europe, Cii) limitations of the AMR data and Ciii) errors in the risk calculations based on AMR data. We reviewed available exposure information specific to Australian vehicle mechanics and AMR data, obtained from the Australian National Occupational Health and Safety Commission, for this evaluation. Results We did not identifY differences in workplace exposures, processes or fibre type among Australian vehicle mechanics compared to vehicle mechanics in other countries. Our analysis of primary AMR data identified several errors in exposure classification and in the assumptions used to calculate relative risk. Conclusions Discrepancies between epidemiologic studies and AMR-based calculations cannot be explained by differences in exposure. These discrepancies are most likely attributable to inadequate occupational information and classification in the AMR from 1986 forward and to erroneous assumptions used to derive relative risk estimates for mesothelioma among Australian vehicle mechanics. Keywords Asbestos; brakes; epidemiology; mesothelioma registry; motor mechanics; motor vehicle mechanics. Introduction The question of whether vehicle mechanics have an increased risk of developing mesothelioma from their exposure to asbestos during brake work has been addressed in numerous epidemiologic studies in North America and Europe [1-19] (Table 1) and summarized in two meta- 'Exponent, Inc., 149 Commonwealth Drive, Menlo Park, CA 94025, USA. 2Department of Ep,demIOlogy, School of PublIc Health, UniversIty of California, Los Angeles, Box 951772, 650 Charles E. Young Drive, Los Angeles, CA 90095, USA. 3Exponent, lnc., 500 12th Street, SUlte 220, Oakland, CA 94607, USA. 'Exponent, Inc., 420 Lexmgron Avenue, Suite 1740, New York, NY 10170, USA. 'Department of Epidemiology, RollIns School of Public Health, Emory University, 1518 ClIfton Road, NE, Room 430, Atlanta, GA 30322, USA. Correspondence to: Mlchael A. Kelsh, Exponent, 149 Commonwealth Dnve, Menlo Park, CA 94025, USA. Tel' + 1 650 688 1764; e-mail: mkelsh@exponent.com analyses [20,21] and a qualitative review [22]. The studies found no evidence of an association between work as an auto mechanic or brake work and mesothelioma. This finding has been disputed, however, with authors citing case reports of mesothelioma among auto mechanics and limitations in the epidemiologic studies [23,24]. The epidemiologic findings are in disagreement with calculations using the Australian Mesothelioma Registry (AMR). In a document prepared for the World Trade Organization (WTO), one panellist estimated that vehicle mechanics have a 10fold increased incidence of mesothelioma based on data from the AMR [25]. AMR data were also used in similar calculations that suggested increased risk [26,27]. We explored three possible explanations for this apparent discrepancy: (i) exposure differences between North American and European versus Australian vehicle mechanics, (ii) lImitations of the AMR data and (ui) errors in the risk calculations using the AMR data. The Author 2007. Published by Oxford University Press on behalf of the Society of Occupational Medicme. All nghrs reserved. For Permissions, please email: journals.pennissions@oxfordjournals.org Table 1. Summary of findings and key characteristics of epidemiologic studies of mesothelioma among vehicle mechanics First author Publication Study year type Exposure category Exposed or Exposed observed controls or Total cases Total controls Z...'Q."., Relative .... risk 0 (") Jiirvholm Hansen Gustavsson McDonald Teta 1988 1989 1990 1980 1983 Spirtas 1985 cases Cohort Car mechanics Cohort Auto mechanics I" Cohort Bus garage workers 2 Case-control Garage 11 Case-control Automobile repair and 1 related service Case-control Brake lining installation or N/A e expected estimate (") cases and 95% CI ~ ::l 0 21 905 workers followed 19 years for incidence and 13 years for mortality NA Z ;J> 21 800 workers followed 10 years NA t"' 695 workers followed 35 years for mortality and 27 years for incidence NA ~ trl 12 156 156 0.91 b (0.35-2.34)b .t..l. 5 147 464 0.65 (0.80-5.53) (") Z trl N/A 259 259 1.0 (0.6-1.6) repair Woitowitz 1994 Case-control Motor vehicle mechanics 16 28 324 497 0.87b (0.43-1.70)b Teschke 1997 Case-control Vehicle mechanics 6 20 51 154 0.8 (0.2-2.3) Agudo 2000 Case-control Mechanics, motor vehicles 3 14 54 162 0.62b (0.1l-2.36)b Hansen 2003 Case-control Repair of motor vehicles 10 12.5 N/A N/A 0.8 (0.4-1.5) and motorcycles Hessel 2004 Case-control Brake lining installation or 12 28 147 358 1.04 (0.46-2.22) repair Welch 2005 Case-control Tire or brake repair 8 6 24 24 1.50 (0.36-6.45) Rolland 2006 Case-control Skilled auto mechanic: NA NA 375 714 1.15 (0.53-2.47) maintenance or repair Peterson 1980 PMR Mechanics and repairmen, 0 0 NA NA 0 automobile (n = 1833 deaths)C Olsen 1987 PIR Repair of motor vehicles 0 N/A NA NA 0 and motorcycles (total number of deaths NA)C Coggon 1995 PMR Motor mechanics 12" 26 NA NA 0.46 (0.24-0.80) (n = 15 435 total deaths)C Milham 2001 PMR Automobile mechanics 7 9 NA NA 0.75 (0.30-1.55)b and repair workers (n = 10473 total deaths)C NIOSH 2002 PMR Automobile mechanics 15" 19 NA NA 0.81 (0.45-1.34)b (n = 66 787 total deaths)C McElvenny 2005 PMR Motor mechanics (total 60 80b (Appendix) number of deathsc NA) NA NA 0.48 (0.37-0.62) Cl = confidence interval: NIOSH. National Tn.titute of Occuratlnnal Saferv and Health; PTR = proportionate InCIdence rano; PMR = proportionate mortality rano: NA = not applicable and N/A = not avaIlable. ElResults presented for pleural cancer. "values have been calculated usmg Ep!Tnfo v3.2 (http://wwwcdc.govIEPITNFO/epiinfo.htm) CTotal number of deaths (all causes) among auto/vehicle mechanics. M. A. KELSH ETAL. MESOTHEUOMA IN AUSTRAUAN VEHICLE MECHANICS Page 3 of 9 Methods To evaluate potential exposure differences, we considered three questions regarding exposure characteristics of Australian versus North American/European vehicle mechanics: (i) Are exposure levels to airborne asbestos fibres higher in Australia? (ii) Are there differences in the brakehandling procedures? and (iii) Do the asbestos fibre types used in brake linings differ? Published studies and unpublished reports were the source of information used to address these three exposure-related questions [28-42]. To better understand the types of data included in the AMR, we reviewed the literature describing AMR data collection procedures and evaluated de-identified information from the AMR pertaining to individuals reportedly engaged in brake manufacturing and/or repair. The AMR began as the Australian Mesothelioma Surveillance Program or the 'Program' in 1980 [43]. For each case, a full occupational and environmental history was obtained by direct interview [43]. Starting in 1986, the Program was replaced by a 'Register', which involved less systematic data collection resulting in less rigorous occupational and environmental data. Since 1986, ,,-,40% of the exposure information is collected via a short questionnaire with the remaining collected by other programs [44]. Beginning in 1996, the National Occupational Health and Safety Commission (NOHSC) ofAustralia reports of AMR data listed a category called 'circumstances of exposure' that included 'brake linings-made/repaired'. The final NOHSC publication to provide information on this category included 78 total mesothelioma cases with occupational and non-occupational brake work (59 cases of exclusive exposure to brakes and 19 cases with other asbestos exposures) for the period 1986-2001 [44]. From NOHSC, we obtained de-identified hard-copy forms and electronic data pertaining to these 78 cases. Because the electronic database contained substantially less information, we relied on the hard-copy forms for our analysis. Through detailed record review, we identified which of the 78 cases from the AMR would be classified as motor mechanics according to the rules of the Australian Census. Classifying AMR data proved difficult given the paucity of information and NOHSC has now abandoned the use of the 'circumstances of exposure' categories in its reports and uses only industry and occupational history information. Results A comparison of asbestos exposure levels in Australia, USA and Europe is presented in Table 2. Exposure surveys among Australian vehicle mechanics report generally low 0.1 f/cc) airborne asbestos concentrations. In the USA and Europe, personal sample concentrations ranged from 0.002 to 2.33 flcc for passenger cars and light trucks and from <0.003 to 7.09 flcc for heavy trucks and buses. For passenger vehicles and light truck repair, 8-h timeweighted average (TWA) concentrations ranged from <0.002 to 0.68 flcc (mean, 0.04 f/cc). For heavy trucks and buses, the mean reported 8-h TWA was 0.2 flcc (range, 0.002-1.75 f/cc). Exposure levels have decreased over time in both Australia and the USA [29,3236,39,41]. Thus, available data show no discernable differences in Australian workplace asbestos concentrations (peak or TWA asbestos exposures) compared to North America and Europe. However, these data are limited by lack of exposure information for earlier time periods, which makes them somewhat less relevant due to the long latency of mesothelioma. On the other hand, studies designed to simulate historical mechanic exposures did not find asbestos concentrations above the current US Occupational Safety and Health Administration permissible exposure limit of 0.1 flcc [42]. Brake repair cleaning practices used in Australian garages induded use of aerosol brake cleaners for dust control and degreasing, squirt bottles for washing brake parts, spraying compressed air to dry brake assemblies and removing dust using a scalpel and then dry wiping [29]. In the USA, brake-cleaning methods included the above methods, plus wet and dry brushing and various vacuum enclosures. Surveys of both Australian and American garages provide no evidence that grinding, sanding or drilling, which could result in additional exposures, were more common in Australia than in the USA. These activities were rarely undertaken after the late 1970s in either country [29,39,41]. In Australia, as in North America and Europe, raw chrysotile asbestos was used in the manufacture of brake disc pads, brake linings and brake blocks [29]. Armstrong et al. [45] stated that crocidolite was used in brakes in Western Australia; however, there are no published data that confirm this statement. Given that amosite, crocidolite and other amphibole asbestos varieties were not considered suitable for brake products [39] and that chrysotile asbestos is much softer than the amphiboles, much easier to process, more abundant and has good heat resistance, it is unlikely that crocidolite was used in brakes. In our evaluation of the original AMR data, we identified 48 of the original 78 cases that could be considered 'possible' motor mechanics after inclusion of all potentially related occupational categories such as apprentice mechanic, motor mechanic of farm machinery, diesel motor mechanics and motor mechanics working in the armed forces (Figure 1). The thirty remaining cases were (i) individuals who were not 'professional' vehicle mechanics, (ii) worked near mechanics but did not personally conduct the work, Ciii) worked in brake manufacturing or (iv) women whose husbands were Table 2. Summary of exposure surveys of asbestos levels among motor vehicle shops Author PopUlation/site Work activity Sample typelduration Australia Frands [30] VOHSC [31] VOHSC [31] NICNAS [29] Measurements by factory inspectorate in New South Wales, Australia Survey conducted by Victoria Department of Labour of Australian automotive firms Same as above Ten surveys in Western Australian brake shops, 1979-1989 Blowing out brake drums finishingl riveting 'Large specialist automotive brake and clutch firms' 'Smaller independent firms' 'Brake maintenance', one sample 'grinding brake discs and linings' NA NA NA NA P (one sample 175-185 min; two samples 3 h; remainder duration NS) Number of samples NA NA NA NA 6 NICNAS [29] Same as above 'Brake maintenance', A (two samples 9 including belt/radius 10 min; remainder grinding duration NS) Results ;=<Jq to "" Comments .Q.., ;c <1 flml 2-4 flml <0.1 flml 0.2-0.3 flml, TWA <0.1 flml 0 Cl iCl Presented at Second C Australian ~ Pneumoconiosis '-l Conference Z 'Occasional' excursions r up to 1.0 fiml ~ tIl .(.:.;.) NA Cl tIl All but one Report noted 'majority' sO.1 flml of fibres <0.1; limited (by MFM), information so unsure single sample of peak versus TWA collected in exposures 1983 = 0.7 flml (3 h duration) Two of nine exceeded Same as above; did detection limit not include results (DIN = 0.01-D.5 fim!) from brake bond ing Belt grinding: 1979, 0.4 flml, 10min Task NS: 1982, 10 f/ml; duration NS NICNAS [29] NICNAS [29] Same as above Aftermarket survey of five automotive service garages in 1996 (four automobile, one bus) Yeung et al. [28] Four Australian garages (three for passenger cars and light vehicles, one for truck brakes) 'Brake maintenance' Drum and disc brake changing Type and duration NS P, A (1-2 h, MFM analysis) Servicing brakes P (77-125 min) 5 5 (P), 31 (A), collected from 10 workers <0.2-1.3 fiml <0.05 flml (P), <0.03 flml (A) 4 ND (DLV = 0.05 fiml) Same as above; samples collected 1981 Stated that service stations 'rarely undertook cutting, grinding or sanding' activities; <0.01 asbestos equivalents by TEM Samples collected in 1995 Table 2. Continued Author Population/site Work activity Sample type/duration Number of samples Results Comments Europe Hickish and Knight Car and truck exposures Servicing brakes P (2 X 45 min, 6 TWA 0.68 flcc (car), Evaluated use of [32] in England collected >8 h) TWA 1. 75 flcc (truck) compressed air, samples collected during 11 brake jobs ~ Riidelsperger et al. [37] Service stations for cars, Servicing brakes P, A 3-60 min) 31 samples (car), 36 Mean 0.04-0.12 flcc ~ trucks and buses in samples (truck and bus) (car), mean 0.05-0.39 Germany flcc (truck and bus) ~ Plato et al. [40] Repair shops in Sweden Vehicle repair work P (8 h) 103 mechanics TWA 0.02-0.20 flcc Exposure data collected :r: from 1976 to 1988 t>l USA Johnson et al. [33] NIOSH survey of seven Servicing brakes P, A (5.7 h TWA, 94 TWA, 6 peak TWA 0.01-0.20 flec, Evaluated various ~ t-- garages 0.5-3.0 min for peak) 0.45-14.54 flcc (peak) cleaning techniques ~ Roberts [34] NIOSH study of one Servicing brakes P (4.3 h TWA, 1 min 1 TWA, 1 peak TWA 0.04 flcc, Re-evaluation of one garage for peak) 0.33 flcc (peak) garage included in ~ Johnson et al. ~ Roberts [35] NIOSH study of one Servicing brakes P (6.2 h TWA, 1-3 2 TWA, 2 peak TWA 0.006-0.04 f/cc, Evaluated cleaning with ~ garage min for peak) 0.25-0.37 flcc (peak) compressed air and solvent ~ Roberts and Zumwalde NIOSH survey of six Servicing brakes P, A (2.3-6.2 h TWA, 13 TWA, 23 peak TWA 0.01-0.28 flcc, Evaluated various [36] garages 0.33-21 min for peak) 0.00-15.0 flcc (peak) cleaning techniques Z Moore [38] Sheehy et al. [39] 31 US garages NIOSH study of Servicing brakes Servicing brakes P (10-60 min; mean 29 min) P, A (120 min) 35 83 P <0.01-0.15 flcc Evaluated various cleaning techniques ~ <0.003-0.016 flcc Evaluated various ~ ~ engineering cleaning techniques control technologies in ~ garages Paustenbach et al. [41] Review of US, European Brake repair activities P ~200 TWA <0.002-0.68 flcc ~ and Australian exposure (car), TWA 0.002-1. 75 n Blake et al. [42] data Exposure simulation of brake repair Four brake drum replacement P, A (262-395 min) 6 P, 9 A flcc (truck) 0.0042-0.0937 flcc (P) Evaluated filing, sanding ~ 0.0010-0.0031 flcc (A) and arc grinding ~ ntrl A, area (statIc) sample; DLV, detection linlit value; flce, fibres per cubic cennmetre: f/ml, fibres per millilitre; MFM, standard membrane filter method (hght ffilcroscopy); mm, minute; NICNAS, NatIonal lndustnal ~ ChemlCals Notificatlon and Assessment Scheme; NIOSH, National Institute for Occupatlonal Safety and Health; NA, not applicable or not available: ND, not detected; NS, not stated; P, personal sample; TEM, n transmissIOn electron microscopy and VOHSC, Victoria Occupational Health and Safety CommIssion. ~ ;,;= ~ ...v- o 'l: Page 6 of9 OCCUPATIONAL MEDICINE I Definitely not motor mechanics n=30 Total cases m category 'brake linings made/repaired' n= 78 I I Possible motor mechanics n=48 I I I Unclear If motor mechanics n= 10 Insufficient info Defmite motor mechanics n=38 I I Other asbestos exposures possible n=20 I One Job recorded n=9 I No other asbestos exposures mentIOned n = 18 I I Two Jobs recorded n=6 I Three or more jobs recorded n=3 Figure 1. Analysis of AMR data. mechanics (Figure 1). None of these cases would be classified as a 'motor mechanic' using Census coding procedures. Thirty-eight cases of the possible 48 possible mechanics were identified as 'definite' motor mechanics; of whom, 18 had no other recorded asbestos exposure. However, 15 of those 18 individuals had only one or two jobs recorded raising concerns about the completeness of their occupational histories. Twenty of the 38 cases had other occupational asbestos exposures determined by matching their occupational histories against a previously published list of asbestos-related jobs [5]. Calculations that used the AMR data to estimate the relative risk of mesothelioma for Australian vehicle mechanics have been presented in various reports and letters [25-27]. In a WTO report regarding human health risks associated with chrysotile asbestos, one of the panellists stated that the AMR data included 58 mesothelioma cases among brake mechanics with no other exposure to asbestos. This number, combined with an estimated 200 000 current and former vehicle mechanics in Australia to calculate disease rates, would result in a disease rate that is rv 1O-fold higher than background mesothelioma rates assumed to be one to two cases per million! year [25]. This background rate, however, is likely too low for Australia, given the potential environmental crocidolite exposure in certain regions of the country [46,47] . Based on our review of AMR records, not> 18 individuals (instead of 58) potentially fit the definition of 'brake mechanics with no other exposures to asbestos'. Moreover, only three of those cases seem to have a detailed occupational history with at least three jobs recorded. In addition, the size of the population ofvehicle mechanics cannot be accurately estimated because it should include all former and current mechanics over the previous 25-40 years. The estimate for the population size calculation was based on the assumption that the ratio of current to ever motor mechanics is 1:2; however, in the USA, the ratio of current to ever mechanics was M A KELSH ETAL.: MESOTHEUOMA IN AUSTRAUAN VEHICLE MECHANICS Page 7of9 estimated to be 1:5 [48]. Without better methods, the actual numbers of current and former motor vehicle mechanics remain unknown. Using the same AMR data, Leigh and Driscoll [26] provide a table of lifetime risk of 0.7% for vehicle mechanics, compared to 0.39% for 'All Australian Men'. However, these risk calculations have the same limitations as the WTO report and in addition, they do not take into account competing risks and age-specific relative risks or disease rates. Discussion Our review identified no discernable differences in workplace levels of exposure, processes or fibre type among Australian vehicle mechanics compared to vehicle mechanics in other countries. Instead, our analysis of primary AMR data identified several errors in exposure classification and in the assumptions used to calculate relative risk. Another proposed explanation for this discrepancy is that the numerous epidemiologic studies are flawed and mask a 'true' increased risk [23,24]. A full review and discussion of each study's methods and quality are beyond the scope of this paper, but have been addressed elsewhere [21,22]. Nevertheless, the consistency of findings across numerous epidemiologic studies conducted by various researchers in different populations using a variety of study designs and data collection procedures argues against the presence of systematic bias in the same direction in all those studies. Ongoing disease surveillance based on accurate cancer data as recorded in a registry system such as the AMR can provide important public health information [43, 44]. However, we noted that the use of the AMR data to accurately classify individuals as motor mechanics is problematic. This is primarily due to incomplete work histories and frequent job misclassification. Overall, we observed that the mesothelioma rate calculation and risk estimate in the WTO report (i) overestimated the number of mesothelioma cases among motor mechanics without other occupational asbestos exposures, (ii) used an unverifiable estimate for the number of motor mechanics and (iii) underestimated the background rate for mesothelioma. This research is the first study to evaluate exposure classification of vehicle mechanics work in the AMR data; however, our analysis should not be viewed as an attempt to estimate the actual risks of mesothelioma among vehicle mechanics. We did not conduct a formal data collection nor did we have the data to adequately enumerate the population at risk. The most reliable method of identifying occupational risk using AMR data would be a formal epidemiologic study involving systematic case ascertainment, rigorous work history data collection and careful enumeration of the source population. Currently available data on vehicle mechanics from existing epidemiologic studies should be used instead of 'rough' estimates or calculations. Key points There is a discrepancy between the reports of increased risk of mesothelioma among motor vehicle mechanics in Australia and the null findings from published epidemiologic studies in North America and Europe. Unlike North American and European studies, the Australian reports are based on informal calculations using the data from the AMR. The observed discrepancy cannot be explained by the differences in asbestos exposure among motor mechanics in Australia and in other countries; however, there seem to be several errors in the AMR data and in the assumptions used to calculate relative risk. Estimating risks should be done using carefully designed epidemiologic studies and not from calculations based on case-only data. Funding DaimlerChrysler Corporation; Ford Motor Company; General Motors Corporation. Conflicts of interest All authors have provided scientific consulting services to Daimler Chrysler Corporation, Ford Motor Company and General Motors Corporation in the areas of exposure assessment and epidemiologic evaluation. Some authors have also served as expert witnesses in litigation regarding the potential hazards of asbestos to vehicle mechanics. References 1. Jarvholm B, Brisman J. Asbestos associared tumours in car mechanics. Br J Ind Med 1988;45:645-646. 2. Hansen ES. 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